Educating Practitioners about Pain - PAINWeek

26
news
friDAY
September 9, 2011
RECAP
Managing Risk as Part of a Tailored Approach to
Pain Management
Treating medium- and high-risk patients for pain requires rigorous testing, an individualized approach, and realistic expectations
“This is not
Burger King.
You do not get
to have it ‘your
way’ when it
comes to pain
meds. They are
called ‘controlled
substances’ for a
reason.”
Thursday morning at PAINWeek 2011, Ted W. Jones, PhD, a clinical
psychologist at the Behavioral Medicine Institute in Knoxville, TN,
and Darren McCoy, NP, MSN, an adjunct faculty member and
clinical preceptor at the University of Tennessee College of Nursing in
Knoxville, TN, offered a detailed account of how their practice, Pain
Consultants of East Tennessee (PCET), assesses medium- and high-risk
pain patients and treats them using prescription opioid medications.
McCoy stressed that providers who are planning to treat patients
with opioids “have to do some kind of risk assessment” to gauge that
patient’s potential to abuse and/or misuse their medications, and noted
that “there are many tools available to do so,” including the ORT,
SOAPP, SOAPP-R, MPQ, DIRE, and others. However, he cautioned that
“it’s not enough to just assess risk; it’s what you do with that data in
treating patients the makes the difference.”
In McCoy’s community, there is no nearby academic or tertiary pain
center to which patients can be referred. This, combined with what he
said was “frequent overprescribing of opioids by other providers in the
community,” has meant that PCET has had to develop its own detailed
policies and procedures for providing safe and effective care to a
wide range of patients.
Jones said that 33%-70% of patients at PCET are categorized as
medium- to high-risk depending on the measure used to assess them
(he said the SOAPP-R rates higher than ORT, in their experience). The
question for most non-pain specialists when dealing with this population
is whether to treat the patients themselves, consult with a specialist,
or refer the patients to another specialist provider. For practices
that do not have access to these resources, Jones said that there are
several general principles to keep in mind when treating high-risk patients.
Providers should increase the frequency and number of monitoring
methods they use, including the use of urine drug testing and
pill counts. He also recommended that providers refer to their state’s
prescription drug monitoring program (PDMP) if their state has one.
Jones said that increased office visits are important, and suggested
that providers limit the use of rapid-onset and short-acting opioids in
this patient population.
If patients object to these measures (especially the limits on the type
and amount of medications the practice will prescribe), McCoy said
that “We remind them that this is not Burger King. You do not get to
have it ‘your way’ when it comes to pain meds. They are called ‘controlled
substances’ for a reason.”
At PCET, the standard practice during the first office visit for a pain
patient is to assess them for risk of misuse and abuse. This includes a
thorough review of their past medical records, checking the Tennessee
PDMP database, and administering a urine drug test. McCoy said
that his practice will try all non-opioid treatments before starting a
patient on opioids, at which point all patients are also required to sign
a medication agreement. McCoy also noted that, although it seems
a simple detail, providers should make sure to document a diagnosis
that supports the use of opioids and that is supported by the clinical
presentation and data. All patients must also go through a “medication
class” that explores addiction vs. dependence, safe storage of
medications, and other important safety and risk management topics.
Other risk management and monitoring strategies recommended by
Jones and McCoy for all patients being treated with opioids include
follow-up urine drug screening at least annually (with more frequent
testing for higher risk patients), conducting pill counts during every
office visit, following daily dosing limits, avoiding the use of easily manipulated
time-release medications with new patients, and perhaps
forgoing the use of potent immediate-release opioids.
McCoy reminded the audience that they should “treat pain at least
adequately, if not aggressively.” Otherwise, he said “it is a setup for
the patient to fail,” which can restrict treatment options even further.
When selecting opioid medications and doses, McCoy recommended
prescribing fewer than 100 doses per month of short-acting opioids
(3-4 doses daily) for all patients. If that does not adequately control
the patient’s pain, then “you should consider shifting to a long-acting
opioid” at a smaller number of doses, he said. He cautioned that shortacting
opioids should be prescribed for “incident or activity-related
pain” and should not be given to supplement time-release opioids.
For patients determined to be “medium risk,” McCoy suggested
starting them on long-acting opioids (especially as they may already
be opioid tolerant). If short-acting medications are used, he recommended
tighter limits on the number of doses prescribed (maybe 30-40
per month). He also recommended more frequent use of urine drug
testing in these patients (at least quarterly). High-risk patients should
not be prescribed short-acting opioids at all, and should have their
urine tested frequently (at PCET, this is done at each visit for these patients).
Random pill counts and random urine drug testing may also be
warranted (pill counts can also be performed by a pharmacist if the
patient cannot make it to the office).
Jones said that PCET runs an “intensive treatment program” for highrisk
patients that requires them to make weekly visits for 12 weeks, followed
by biweekly visits for 24 weeks. Patients are subject to all of
the monitoring measures previously discussed (medication checks, pill
counts, urine drug testing, etc) and must also attend the medication
class. Jones said that this “is really helpful; if nothing else it highlights
the medication agreement.” It also offers the opportunity to talk with
the patients about why the medication agreement is important, the
risks associated with prescription opioids, the reasons why patients
should not share medications, safe storage and disposal practices,
and other topics.
He shared data from the program based on follow-up with 50 patients.
He said that 80% of the patients were started in the program
based on the initial risk assessment, and 20% started after showing
significant aberrant medication behavior. About one-third (32%) of the
patients completed both stages of the program, another third (36%)
were discharged, and 22% left on their own. He said that he was
surprised to find that nearly half (46%) of the patients in the program
demonstrated aberrant behavior. Half of the aberrant patients either
took too many of their medications, had a pill count come up short, or
had a negative urine drug test. He said that about half of the patients
obtained opioids from sources other than their prescriber. Less than
10% of patients used illicit drugs or alcohol.
The evidence shows that this approach appears to be working at
PCET. Jones said that only about 2% of their pain patients get a negative
urine drug screen, only 4% or so test positive for illicit substances.
He said they have about a 15% aberrancy rate overall.
Key takeaway points:
• The more you can do on the front end of treatment to help people,
the better it is for patients, and the longer they will stay in treatment.
• The importance of documentation cannot be overstated. Explain
what you’re doing and why you’re doing it.
• Be realistic about what you can do during treatment, and help the
patient be realistic, too.
• Individualize care and stratify risk.
• Understand that not all patients will be helped by opioids.
• Know the limits of UDTs. Don’t react inappropriately and know
the cut-off limits. Get to know the people at the lab you use and
consult with their toxicologists. Be fair to your patients.
• When discharging a patient from your practice, check the local
laws and regulations regarding what you’re supposed to do.
• Consider allowing patients to appeal a discharge in certain cir-